About Medicare Advantage (Part C) Plans
What is a Medicare Advantage plan?
If you qualify for or are already enrolled in Original Medicare, you can choose to enroll in Medicare Part C, more commonly known as Medicare Advantage. Medicare Advantage plans are offered by private health insurance companies and provide Medicare Part A and Part B coverage (hospital and medical benefits).
You might wonder why a beneficiary would choose to enroll in Medicare Advantage. A Medicare Advantage plan generally covers everything that Original Medicare covers, including emergency and urgent care. But, there can be some differences between Original Medicare and Medicare Advantage. Those differences can be in how much you pay out of your own pocket when you receive health care. For example, you might have lower copayments and coinsurance or a smaller deductible.
There can also be differences in the coverage you receive. Some Medicare Advantage plans include routine vision, routine dental, and/or wellness programs. Many plans also include prescription drug coverage; those plans are called Medicare Advantage Prescription Drug plans. (Hospice care is covered by Original Medicare, and hospice benefits continue to be covered by Original Medicare even if you have a Medicare Advantage plan.)
Do be aware that you would remain enrolled in Original Medicare even if you add a Medicare Advantage plan, and you must continue paying your Medicare Part B premiums. However, if you join a Medicare Advantage plan, you won't need and can't be sold a Medicare Supplement plan (Medigap).
Types of Medicare Advantage (Part C) plans
It's important to understand the differences between the types of Medicare Advantage plans to see which works best for you. There are several different types of Medicare Advantage plans:
HMO (Health Maintenance Organization Plan) : Lets you see doctors and other health professionals who participate in its network. If your doctor is already in that network, it could be a good option because you tend to pay less out-of-own pocket with network doctors.
PPO (Preferred Provider Organization Plan) : Covers both in- and out-of-network providers, giving you the freedom to choose any doctor, which can work if you prefer that kind of flexibility.
PFFS (Private Fee-for-Service Plan) : Pays a specific amount for health care services, and the treating doctor has to accept that amount--even if it is less than his or her usual charge. If the doctor doesn’t agree to those terms, then the Health Plan will not cover services through that doctor.
SNP (Special Needs Plans): Are especially for people who have certain special needs. The three SNP plans cover Medicare beneficiaries living in institutions, those who are dual-eligible for Medicaid and Medicare, and those with chronic conditions such as diabetes, End Stage Renal Disease (ESRD), or HIV/AIDS. This type of plan always includes prescription drug coverage.
HMO-POS (Health Maintenance Organization - Point of Service Plan): Covers both in- and out-of-network health services, but at different rates. You pay less out of pocket when you go to in-network doctors, labs, hospitals, and other health care providers.
MSA (Medical Savings Account Plan) : Includes both a high deductible and a bank account to help you pay that deductible. The amount deposited into the account varies from plan to plan. The money is tax-free as long as you use it on IRS-qualified medical expenses, which include the health plan's deductible.
Eligibility for Medicare Advantage
Medicare Part C eligibility is based on your membership in or eligibility for Original Medicare, Part A and Part B (except if you have ESRD). Generally, if you have Medicare Part A and Part B, you are eligible for Medicare Part C. However, you must live in the service area for the Medicare Advantage plan that you're considering.
If you have other health insurance coverage, for example through an employer or union, ask your plan administrator about that plan’s rules before you enroll in a Medicare Advantage plan. In some cases, you may lose your other coverage if you enroll in the Medicare Advantage plan and you may be unable to get it back if you change your mind later.
Enrollment in Medicare Advantage
You may only enroll in a Medicare Advantage plan during specified election periods:
Initial Coverage Election Period: You can enroll in Medicare Advantage or Medicare Advantage with prescription drug coverage when you first become eligible for Medicare. Your Initial Coverage Election Period (ICEP), is a seven-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. If you are under age 65 and you receive Social Security disability, you qualify for Medicare in the 25th month after you begin receiving your Social Security benefits. If you fall into this category, you may enroll in a Medicare Advantage plan 3 months before your month of eligibility, during the month of eligibility, and 3 months after the month of eligibility. For example, if your Medicare Part A and Part B coverage begins in May, your Medicare Advantage IEP is February through August.
Annual Election Period: If you are already enrolled in Original Medicare, then you must wait until the next enrollment period to sign up for Medicare Advantage. The Annual Election Period (AEP) is October 15 through December 7 every year. The plan coverage you choose during the AEP begins on January 1 of the next year.
Disenrollment: If, after enrolling in a Medicare Advantage plan, you change your mind, you can switch back to Original Medicare from January 1 through February 14 each year. If you would be losing prescription coverage as a result of the switch, you can also sign up for a Medicare Part D standalone prescription drug plan during this time, if you wish.
Special Election Period: Generally, once you enroll in Medicare Advantage, you stay enrolled until the next Annual Election Period (AEP) opens. However, there are some life events that might qualify you for a Special Election Period (SEP) during other times of the year, so you can make a change to your Medicare Advantage coverage. Some examples of these life events include (but aren’t limited to):
- Moving outside your Medicare Advantage Plan's service area
- Qualifying for Extra Help (a program to help you pay for prescription drugs)
- Moving into an institution (such as a nursing home)
Medicare has neither reviewed nor endorsed this information.